Healthcare Provider Details

I. General information

NPI: 1194836692
Provider Name (Legal Business Name): JACQUELYN J HOFFMAN RD CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 09/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 TROY SCHENECTADY RD SUITE 218
LATHAM NY
12110-2490
US

IV. Provider business mailing address

711 TROY SCHENECTADY RD SUITE 203
LATHAM NY
12110-2442
US

V. Phone/Fax

Practice location:
  • Phone: 518-782-3839
  • Fax: 518-782-3761
Mailing address:
  • Phone: 518-782-3823
  • Fax: 518-782-3799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number005808
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: